Clinical Characteristics and Short-Term Outcomes of Pediatric Lymphoma: A Retrospective Cohort Study from a Large Tertiary Hospital in a Low- and Middle-Income Country

Clinical Characteristics and Short-Term Outcomes of Pediatric Lymphoma: A Retrospective Cohort Study from a Large Tertiary Hospital in a Low- and Middle-Income Country | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Clinical Characteristics and Short-Term Outcomes of Pediatric Lymphoma: A Retrospective Cohort Study from a Large Tertiary Hospital in a Low- and Middle-Income Country Dania Abuhalima, Dima Malhis, Zeina Qadi, Adham Abu Taha, Sultan Mosleh, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5539431/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Sep, 2025 Read the published version in Scientific Reports → Version 1 posted 6 You are reading this latest preprint version Abstract Background The incidence of childhood cancer has increased, with lymphoma being the third most common malignancy in children and showing improved survival rates. This study aimed to analyse the demographic, clinical, and outcome data of pediatric lymphoma patients, compare the characteristics of the HL and NHL subtypes, and evaluate treatment outcomes. Methods A single-center retrospective cohort study was conducted at An-Najah National University Hospital (NNUH) in Palestine from 2013–2023. Seventy-five pediatric patients (≤ 18 years) newly diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) were included, and data from electronic medical records were used. Follow-up data were analysed via Kaplan–Meier survival curves to determine event-free survival (EFS) and overall survival (OAS). Results This study revealed a male predominance in both NHL (1.9:1) and HL (1.3:1) patients, with a mean age of 9 years for NHL patients and 10 years for HL patients. The majority of patients were from the West Bank (56%) or Gaza (44%). NHL patients commonly presented with GI symptoms (31.7%), whereas HL patients (70.6%) presented with neck masses. B symptoms were more common in HL patients (55.9%). The tumor stage also differed, with NHL often being stage III and HL being stage II. The predominant subtypes were Burkitt’s lymphoma (BL) for NHL and classical nodular sclerosis for HL. Overall survival was 96%, with 4% mortality. During the follow-up period (mean 26.5 ± 18 months), 84% of the patients had events, with 86.7% of patients remaining event-free. Relapse occurred in 13.3% of patients, predominantly in the NHL group, and the prevalence of OAS was 96%. The 2-year event-free survival (EFS) rate was 85.1%, and the 2-year overall survival (OAS) rate was 96.6%, as estimated via Kaplan‒Meier survival analysis. Conclusion Our study provides insights into the clinical characteristics and short-term outcomes of pediatric lymphoma patients in Palestine. Pediatric lymphoma is more common in males and primarily affects children over 10 years of age. HL is less prevalent, has a higher survival rate, and most commonly presents with a neck mass. In contrast, NHL is more common, is associated with higher relapse and mortality rates, and often presents with gastrointestinal symptoms. Burkitt’s lymphoma (BL) is the most common NHL subtype and is not strongly associated with B symptoms. These findings emphasize the importance of early diagnosis and continuous follow-up in optimizing treatment outcomes. Further studies with larger cohorts and longer follow-up periods are needed to validate these findings and assess long-term survival and cure rates. Health sciences/Diseases/Cancer/Paediatric cancer Health sciences/Health care/Diagnosis/Neoplasm staging Lymphoma Pediatric patients Treatment outcome Retrospective studies Figures Figure 1 Figure 2 Figure 3 Introduction Lymphoma, a malignancy affecting the lymphatic system, ranks as the third most prevalent cancer among children. Hodgkin lymphoma (HL) manifests in two primary forms: HL, which constitutes 6% of childhood malignancies, and non-Hodgkin lymphoma (NHL), which accounts for 7–8% of pediatric cancers 1 , 2 . HL, known for its high cure rates, presents pathologically as classical and nodular HL, with nodular sclerosis comprising the majority of childhood cases 3 – 5 . There are four main types of childhood NHL: lymphoblastic lymphoma (LL), which is mainly T-cell lymphoma and anaplastic large-cell lymphoma (ALCL); Burkitt’s lymphoma (BL), which is the most common NHL in children; and diffuse large B-cell lymphoma (DLBCL) 6 . HL comprises 6% of childhood cancers in wealthy countries. It occurs in children and adults, and its incidence is the highest in teenagers 15–19 but three times lower in children aged 10–14, 5–9, and 0–4 years. A significant male-to-female ratio of 3:1 is observed in children younger than 10 years 7 . NHL, a type of cancer, accounts for 7% of childhood cancers and primarily occurs in the second decade of life. It is more common in whites and males and rarely affects children under three years of age 7 . NHL has an age-adjusted incidence rate of 1.1 per 100,000, which is greater than the HL rate of 0.6 per 100,000 among children under the age of 15 8 . HL risk is linked to a family history of the first relative affected, Epstein–Barr virus (EBV) activation, and primary immune deficiency 9 – 11 . The risk of NHL increases with past cancer treatment 12 . EBV infection may contribute to the development of NHL 13 , and human immunodeficiency virus (HIV) is strongly associated with the development of NHL 7 . Lymphomas have significant clinical and molecular variations, affecting treatment approaches 14 . Regardless of the patient’s presentation, the gold standard for diagnosis is an excisional biopsy, which is necessary for pathological classification 15 . After that, further classification is performed by staging depending on the site and B symptoms 16 . Different lymphomas require different treatment strategies depending on their biological features 14 . Treatment outcomes have improved in well-resourced countries in recent years, with the 5-year relative survival rate of HL increasing to 99% and that of NHL increasing to 85–95% 8 , with relapse being the principal cause of treatment failure 17 . However, in regions with limited resources, such as Palestine, these outcomes may not be as favourable owing to challenges such as delayed diagnoses and limited access to advanced diagnostics and treatment. Although regional studies on pediatric hematologic cancers exist, most focus on leukemia rather than lymphoma. For example, studies from An-Najah National University Hospital in Palestine and Gaza City have reported mainly on pediatric leukemia, with limited data on lymphoma treatment and outcomes 18 , 19 . In neighboring regions, studies have noted a higher incidence of Burkitt’s lymphoma in Gaza and the West Bank, but specific treatment outcomes for pediatric lymphoma are scarce 20 . Research from Israel on pediatric NHL has shown better survival rates due to access to advanced care, although these findings may not be fully applicable to Palestine 21 . This study aims to address this gap by focusing specifically on pediatric lymphoma in Palestine and analysing the clinical features and short-term outcomes of pediatric lymphoma patients treated at NNUH during our follow-up period. By providing much-needed data, this study contributes to the understanding and treatment of pediatric lymphoma in resource-limited settings. Our objectives were to study the clinical profile of pediatric lymphoma patients from 2013–2023 in terms of demographic data; describe the clinical history of patients at presentation and admission; and review labs for initial admission, including complete blood count; lactate dehydrogenase (LDH); bone marrow (BM) biopsy; immunohistochemistry; and whole-body computed tomography (CT) and positron emission tomography (PET) scans. Methods Study Design and Setting A single-center, retrospective cohort study was conducted in 2023 at NNUH, a leading referral cancer center in the West Bank and Gaza, Palestine, to study the clinical profile and treatment outcomes of pediatric lymphoma patients treated from 1st Jan 2013 to 31st December 2022. Study population and Sampling Among the 96 identified patients, 75 pediatric patients (≤ 18 years) with diagnosed HL or NHL treated at NNUH met the inclusion criteria. Patients were excluded if they were diagnosed at NNUH but chose to start treatment at another institution (n = 9), had relapsed disease at initial presentation (n = 5), or had incomplete medical records (n = 7). Data collection The collected data included demographic factors (age, sex, residence), clinical presentation (e.g., neck mass, B symptoms), lymphoma type and subtype (HL or NHL), tumor site (e.g., head/neck, mediastinal), staging (Ann Arbor for HL, St. Jude for NHL) 22 , 23 , B symptoms, LDH levels (< 320 or ≥ 320 U/L) 24 , and CNS and BM involvement. The outcome measures included death, relapse, remission, overall survival (OAS), and event-free survival (EFS) rates. Relapse was defined as the recurrence of lymphoma after remission, which was identified by positron emission tomography (PET) or other diagnostic imaging, such as computed tomography (CT), magnetic resonance imaging (MRI), or chest X-ray. Remission was defined as the absence of detectable disease activity on diagnostic imaging following treatment at the last recorded follow-up. Cures that require sustained remission over a prolonged period, typically five years or more, as suggested by the National Cancer Institute, or up to 10 years, as suggested by Cancer Research UK 25 , 26 , could not be evaluated because of the study’s limited follow-up duration (mean 26.5 ± 18 months). Given this timeframe, remission and EFS were used as primary outcomes, as they better reflect the short- to medium-term prognosis in pediatric lymphoma patients. Each patient's OAS status was determined on the basis of their survival at the last hospital follow-up. EFS and OAS were estimated via Kaplan‒Meier survival analysis. EFS was defined as the time from diagnosis to the first documented relapse or death from any cause, with patients who had not experienced an event at their last follow-up being censored. OAS was defined as the time from diagnosis to death from any cause, with patients who were alive at their last follow-up being censored. Survival probabilities were calculated at 2 years (24 months) on the basis of Kaplan‒Meier estimates rather than direct event counts. Patients who were transferred to another institution were censored at their last known follow-up to ensure accurate survival estimates without overestimation of mortality. Statistical methods The data were analysed via IBM SPSS v.29.0. Continuous variables are presented as the means ± standard deviations (SDs) or medians with interquartile ranges, whereas categorical variables are reported as frequencies and percentages. The chi-square test or Fisher’s exact test was used to analyse categorical variables. Descriptive and inferential analyses were conducted, with statistical significance set at P < 0.05. Patients who were transferred to another hospital after completing their full treatment at our center were included in the analysis, as they met the inclusion criteria and were followed until transfer. Since their outcomes were known up to their last follow-up, they were handled as follows: In the EFS analysis, these patients were recorded as events if they experienced relapse before transfer. In the OS analysis, these patients were censored at the time of transfer in the Kaplan‒Meier survival analysis, as they were still alive at the last follow-up, but their posttransfer survival was unknown. This approach ensures that survival time is accounted for without overestimating mortality. Ethical considerations The study protocol was approved by the Institutional Review Board (IRB) at An-Najah National University and the clinical research center at NNUH. This approval granted access to patient clinical data, which were used exclusively for the purpose of this research. All the data were kept confidential and were not used for any other purpose. All methods were performed in accordance with the relevant guidelines and regulations, including those outlined by the Declaration of Helsinki and the journal's ethical policies for research involving human participants. Results Demographic data After applying the exclusion and inclusion criteria, a collective of 75 pediatric lymphoma patients (56% from the West Bank & 44% from Gaza) were identified from the medical records of the pediatric oncology department of NNUH between 2013 and 2023 for enrollment in the study. Patients were classified into HL (34 patients) and NHL (41 patients) groups, each analysed separately, as shown in Table 1 . A male predominance was evident in both subtypes. The mean age at diagnosis was 9 years for NHL patients and 10 years for HL patients. Table 1 Demographics of pediatric Lymphoma patients Pediatric lymphoma(n = 75) Frequency (%) NHL(n = 41) Frequency (%) HL(n = 34) Frequency (%) P value Age at diagnosis < 5 years 5–10 years ≥ 10 years 14 (18.7) 22 (29.3) 39 (52) 9 (22) 12 (29.3) 20 (48.8) 5 (14.7) 10 (29.4) 19 (55.9) 0.704* Gender Male Female Male: Female 46 (61.3) 29 (38.3) 1.6:1 27 (65.9) 14 (34.1) 1.9:1 19 (55.9) 15 (44.1) 1.3:1 0.476* Residence West Bank Gaza 42 (56) 33 (44) 21 (51.2) 20 (48.8) 21 (61.8) 13 (38.2) 0.484* * Fisher’s exact test Clinical data The process of diagnosing lymphoma involves a thorough approach with imaging techniques such as whole-body CT scans, chest X-rays, and abdominal ultrasounds, when necessary, along with bone marrow and CSF aspirations (the latter only for NHL patients). As shown in Table 2 , most NHL patients (31.7%) first presented with gastrointestinal (GI) symptoms, such as abdominal pain, masses, or signs of obstruction, whereas a majority of HL patients (70.6%) presented with neck masses. This difference in initial symptoms was statistically significant ( p = 0.003). Other symptoms observed included respiratory issues such as chronic cough and rarer signs such as facial swelling or jaw pain. At the time of diagnosis, NHL was mostly found at stage III (41.5%), whereas HL was more often diagnosed at stage II (41.2%), with fewer cases presenting at stage IV, where the disease had spread to bones, the CNS, or other organs. As shown in Table 3 , subtype analysis revealed that BL (56.1%) was the most common subtype of NHL, whereas classical nodular sclerosing Hodgkin lymphoma (73.5%) was the most common subtype of HL, with these differences being statistically significant (p < 0.001). Immunohistochemistry was used to confirm specific markers for each subtype, ensuring accurate classification. Table 2 Clinical Characteristics of Pediatric lymphoma patients NHL n (%) (n = 41) HL n (%) (n = 34) P value Presentation 0.003* Neck mass 12 (29.3) 24 (70.6) Respiratory symptoms 8 (19.5) 2 (5.9) GI symptoms 13 (31.7) 3 (8.8) B symptoms 2 (4.9) 3 (8.8) Others* 6 (14.6) 2 (5.9) B symptoms 0.109** No 26 (63.4) 15 (44.1) yes 15 (36.6) 19 (55.9) Site 0.018** Head/neck 12 (29.3) 16 (47.1) mediastinal 5 (12.2) 10 (29.4) abdomen/pelvis 12 (29.3) 3 (8.8) Generalized 12 (29.3) 5 (14.7) BM involvement 0.369* no 37 (90.2) 33 (97.1) yes 4 (9.8) 1 (2.9) Stage 0.999* I 3 (7.3) 3 (8.8) II 16 (39) 14 (41.2) III 17 (41.5) 13 (38.2) IV 5 (12.2) 4 (11.8) Stage early/advanced 0.819* Early < 3 19 (46.3) 17 (50) Advanced ≥ 3 22 (53.7) 17 (50) LDH 0.154** Less than 320 17 (41.5) 21 (61.8)) More than 320 13 (31.7) 5 (14.7) Not done 11 (26.8) 8 (23.5) *Fisher exact test **Pearson chi square test Table 3 Histopathological findings of pediatric lymphoma NHL Frequency (n = 41) (%) HL Frequency (n = 34) (%) P value LL 13 (31.7) Classical Nodular Sclerosing 25 (73.5) < 0.001 DLBCL 5 (12.2) Classical lymphocyte rich 4 (11.8) BL 23 (56.1) Classical mixed cellularity 4 (11.8) ALCL 0 NLPHL 1 (2.9) *Pearson chi square test LL, lymphoblastic lymphoma; DLBCL, diffuse large B-cell lymphoma; BL, Burkitt's lymphoma; ALCL, anaplastic large-cell lymphoma; NLPHL, nodular lymphocyte predominant HL Outcome Our study followed 75 pediatric lymphoma patients from diagnosis and during the completion of the treatment protocol to the last follow-up, with a mean value of 26.5 ± 18 months. During the follow-up of each patient, regular PET scans or follow-up imaging, such as CT/MRI, were employed to identify relapse and remission. As shown in Fig. 1 , most patients (65, 86.7%), including 29 HL (85.3%) patients and 36 NHL (87.8%) patients, experienced no events during follow-up. patients. Relapse occurred in 10 patients (13.3%), including 5 with HL and 5 with NHL. The time to relapse ranged from 1 to 54 months, with a median of 8 months and a mean of 13 months. Among the patients who relapsed, 4 patients with HL achieved remission after retreatment, whereas none of the NHL patients achieved remission. Five patients (6.7%) remained in relapse after retreatment and were transferred for further care (1 HL, 4 NHL). Since these patients experienced relapse before transfer, they were recorded as events in the EFS analysis. However, because they were still alive at their last follow-up, they were censored at the time of transfer in the OAS analysis via Kaplan‒Meier survival curves. This ensures that their survival time contributed to the analysis without overestimating mortality. Deaths occurred in 3 patients (4.0%), all from the NHL group, including 2 patients who died without preceding relapse and 1 patient who died after relapse; thus, 96% of all patients survived. Overall, 67 patients (89.3%), including 33 HL patients and 34 NHL patients, achieved remission. Total events (relapse or death) were slightly more common in NHL patients (7 patients) than in HL patients (5 patients), and in total, 12 events (relapse or death) were recorded. During the follow-up period (mean 26.5 ± 18 months), 84% of the patients experienced events (a total of 12 events, including relapse or death), with 86.7% of patients remaining event free. The 2-year event-free survival (EFS) rate was 85.1%, and the 2-year overall survival (OAS) rate was 96.6%, as estimated via Kaplan‒Meier survival analysis, as shown in supplementary Figs. 1 and 2. The chi-square test was used to examine associations between patient characteristics and treatment outcomes, and no significant correlations were found between demographic and clinical characteristics and survival or event rates, as shown in Supplementary Tables 1 and 2. Additionally, Kaplan‒Meier survival analysis was performed to compare EFS and OAS between HL patients and NHL patients. The log-rank test revealed nonsignificant differences between the groups ( p = 0.964 and p = 0.208), as shown in Figs. 2 and 3 . Censoring is indicated in the Kaplan‒Meier curves, including for the five transferred patients in the OAS analysis. Discussion Our research on pediatric lymphoma in Palestine represents a pioneering effort, as no such study has been conducted before. Our primary objective was to investigate the clinical characteristics of HL and NHL patients and analyse their outcomes, emphasizing distinctions between the two. Among both HL and NHL patients, males presented a greater prevalence, which aligns with findings from global research studies conducted in Egypt, Korea, the United States, East Asia, Saudi Arabia, and Turkey 27 – 32 . Notably, the male-to-female ratio in our study was approximately 2:1 for both HL and NHL, whereas in the aforementioned studies, it was commonly reported as 2.5:1, 3:1, or 4.5:1. In our study, individuals aged > 10 years emerged as the predominant age group affected by pediatric lymphoma, a trend consistent with findings from research conducted in Korea and the USA 27 , 29 . In contrast, studies in Turkey and India reported a higher prevalence among those aged < 5 years, whereas in Egypt, the (5–10 years) age category stood out 28 , 32 , 33 . Notably, countries exhibiting a predominance of younger age groups are often associated with a higher prevalence of EBV, which is thought to be linked to a younger age of presentation. These regional variations underscore the complex interplay between age demographics and potential viral factors influencing the incidence of pediatric lymphoma 28 , 34 . BL has consistently emerged as the most common pathological subtype of NHL, which aligns with other global investigations 27 , 30 , 32 , 35 . Conversely, HL exhibited variability in the most frequent pathological subtype across studies. Our research and studies in Egypt and the USA consistently identified classical nodular sclerosing as predominant 28 , 36 . Conversely, studies conducted in the UK and India reported that the mixed cellularity type was the most dominant 33 , 37 . In terms of initial presentation, abdominal manifestations such as abdominal masses or abdominal signs/symptoms such as intestinal obstruction predominated in NHL patients, which is consistent with studies in other countries 38 . HL patients predominantly present with neck masses or masses. The tumor’s primary site, which is the primary region of disease concentration or origin, was identified with equal frequency as the most predominant site in three regions—the head and neck, abdomen and pelvis—and generalized in NHL. In a study conducted in Thailand, it was in the head and neck region, and in Korea, the Prague Czech Republic and Turkey, it was mainly in the abdomen 27 , 32 , 35 , 39 . In our study, the majority of patients diagnosed with NHL presented with an advanced stage (≥ stage 3) at the time of diagnosis (53.7%). Conversely, in the HL group, there was an equal distribution, with 50% of patients diagnosed with early-stage disease (< stage 3) and the remaining 50% with advanced-stage disease (≥ stage 3). Interestingly, the literature commonly reports diagnoses of both HL and NHL at advanced stages 27 , 28 , 30 , 33 , 35 . B symptoms were more common in HL patients (55.9%) than in NHL patients (36.6%). This finding was consistent with the literature in the case of NHL, whereas some studies on HL reported that the majority of patients had B symptoms, and others reported that the majority had no B symptoms 28 , 33 . The survival of children and adolescents with cancer has significantly increased over time 40 . For children under 15 years of age, the OAS rate increased to 90% for NHL 41 ,42 and 98% for HL 43 . According to American Cancer Society estimates, the OAS for HL and NHL were 99% and 91%, respectively, for children younger than 14 years. Compared with 98% and 89%, respectively, for children between 15 and 19 years of age 17 . In our study, the survival rate for pediatric lymphoma patients was 96% on the basis of the survival outcome of the last hospital follow-up; 100% of HL patients and 92.7% of NHL patients survived. Similar to a study performed in Bangladesh, a total of 76.5% of patients survived; 100% of HL patients and 60% of NHL patients survived 44 . In our study, relapses were observed in 9 patients, accounting for 12% of all lymphoma patients; 5 (14.7% of those with HL) and 4 (9.8% of those with NHL) of the 5 patients with HL. The EFS rate for paediatric lymphoma patients was 85.1%. Studies performed in Thailand, Korea, and East Asia among NHL pediatric patients reported similar results (71.5% ± 4.3%, 67.7 ± 8.0%, and 84%, respectively, for 5-year EFS 27 , 30 , 35 . In our study, we found no significant associations between OAS or EFS and disease stage (p = 0.35 and p = 0.34, respectively). These findings diverge from those of prior studies, which often reported significant associations 28 , 45 , which might be due to the small sample size of our study or the early transfer of advanced stages, which were excluded from the study. Two studies performed in East Asia and Spain reported that initial LDH levels were significantly associated with OAS and EFS and that higher LDH values were associated with poorer outcomes 24 , 30 . Our study, however, had no significant p value for that association (0.999). Study Limitations The study's limitations include the small sample size of 75 pediatric lymphoma patients, which may limit the ability to identify significant treatment changes or generalize findings. The study was conducted at An-Najah National University Hospital, a referral center for pediatric lymphoma patients in the West Bank and Gaza. However, the hospital may not cover all cases from Gaza or the southern West Bank. The inclusion of data from pediatric cancer treatment hospitals in the West Bank was hindered by missing or incomplete medical records. Additionally, the retrospective design of this study, encompassing data collected from 2013–2023, introduces inherent constraints, including potential inconsistencies in data recording and variations in follow-up durations. Patient inclusion and follow-up periods varied due to factors such as treatment completion without subsequent follow-up or transfer to specialized facilities. Notably, some patients completed their prescribed treatment regimens but did not return for scheduled follow-up assessments, limiting the ability to monitor long-term outcomes and assess sustained remission or potential late relapses. Additionally, five patients transferred to other centers were alive at their last follow-up; however, their posttransfer outcomes remain unknown, limiting the comprehensiveness of our survival analysis. Moreover, logistical and geographic challenges, particularly for patients from the Gaza Strip, limit our ability to conduct the longer-term follow-up necessary to assess cure rates. The mean follow-up duration of 26.5 ± 18 months was insufficient to evaluate long-term outcomes definitively. Determining 'cure' in pediatric lymphoma patients typically requires a follow-up period of five years or more to monitor for late relapse and sustained remission. The relatively short follow-up in this study precludes the assessment of cure rates and may lead to the underestimation of late-occurring events. To mitigate these limitations, future research should consider prospective study designs with standardized data collection methods and extended follow-up periods. Such approaches would enable a more accurate assessment of long-term outcomes, including cure rates, and provide a clearer understanding of the factors influencing survival and remission in paediatric lymphoma patients. Our 10-year study of pediatric lymphoma patients at NNUH provided valuable insights into their demographics and clinical characteristics, highlighting the success of their treatment protocols. However, it also highlights the need for improved cancer registries and a nationwide association for patients to improve communication and care quality. Conclusions Our study provides insights into the clinical characteristics and short-term outcomes of pediatric lymphoma patients in Palestine. Pediatric lymphoma is more common in males and primarily affects children over 10 years of age. HL is less prevalent, has a higher survival rate, and most commonly presents with a neck mass. In contrast, NHL is more common, is associated with higher relapse and mortality rates, and often presents with gastrointestinal symptoms. Burkitt’s lymphoma (BL) is the most common NHL subtype and is not strongly associated with B symptoms. These findings emphasize the importance of early diagnosis and continuous follow-up in optimizing treatment outcomes. However, owing to the small sample size and limited follow-up duration, long-term conclusions cannot be drawn. Further studies with larger cohorts and extended follow-up are needed to validate these findings and assess long-term survival and cure rates. Abbreviations • ALCL • Anaplastic large-cell lymphoma • BL • Burkitt’s lymphoma • BM • Bone marrow • CNS • Central nervous system • CT • Computed tomography • CSF • Cerebrospinal fluid • DLBCL • diffuse large B-cell lymphoma • EBV • Epstein–Barr virus • EFS • Event-free survival • GI • Gastrointestinal • HIV • human immunodeficiency virus • HL • Hodgkin lymphoma • LDH • Lactate Dehydrogenase • LL • Lymphoblastic lymphoma • MRI • Magnetic Resonance Imaging • NHL • Non-Hodgkin lymphoma • NNUH • An-Najah National University Hospital • OAS • Overall survival • PET • Positron emission tomography Declarations Ethics approval and consent to participate : Due to the retrospective nature of this study, the need to obtain informed consent was waived by the An-Najah National University Institutional Review Board (Approval number: Med. Oct. 2023/111) and the Clinical Research Committee of An-Najah National University Hospital (Approval number: CRC_2023_0160). The study was conducted using preexisting deidentified data, and ethical approval was obtained before initiating the research. Consent for publication : Not applicable. Clinical trial number: not applicable. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author upon request. Competing interests : The authors declare that they have no competing interests. Funding : This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions : DA, DM, and ZQ collected and analysed the data and prepared the initial draft of the manuscript under the supervision of AAT, SZ and SM. AAT and SM provided critical revisions and finalized the manuscript. All authors reviewed and approved the final version of the manuscript for submission. 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Serum lactate dehydrogenase level as a prognostic factor in Hodgkin’s disease. British Journal of Cancer 1993 68:6 68, 1227–1231 (1993). Definition of relapse - NCI Dictionary of Cancer Terms. - NCI. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/relapse Why some cancers come back | Cancer Research UK. https://www.cancerresearchuk.org/about-cancer/what-is-cancer/why-some-cancers-come-back Kim, J. S. et al. Treatment Outcomes and Prognostic Factors in Children with Non-Hodgkin Lymphoma at a Single Institution. Clin. Pediatr. Hematology-Oncology . 21 , 86–94 (2014). Ali, N., Mansour, M., Khalil, E. & Ebeid, E. Outcome and prognostic factors of pediatric patients with Hodgkin lymphoma: a single-center experience. J. Egypt. Natl. Canc Inst. 35 , (2023). Childhood Non-Hodgkin’s Lymphoma Survival Rates | American Cancer Society. https://www.cancer.org/cancer/types/childhood-non-hodgkin-lymphoma/detection-diagnosis-staging/survival-rates.html Kyung Suh, J. et al. Clinical Characteristics and Treatment Outcomes of Pediatric Patients with Non-Hodgkin Lymphoma in East Asia. Cancer Res. Treat. 52 , 359–368 (2019). Belgaumi, A. et al. Clinical characteristics and outcome of pediatric patients with stage IV Hodgkin lymphoma. Hematol. Oncol. Stem Cell. Ther. 2 , 278–284 (2009). Karadeniz, C. et al. CLINICAL CHARACTERISTICS AND NON-HODGKIN LYMPHOMA PATIENTS IN A SINGLE CENTER. Pediatr Hematol Oncol 24, 417–430 (2007). Trehan, A., Singla, S., Marwaha, R. K., Bansal, D. & Srinivasan, R. Hodgkin lymphoma in children: Experience in a tertiary care centre in India. J. Pediatr. Hematol. Oncol. 35 , 174–179 (2013). Chiu, B. C. H. & Weisenburger, D. D. An update of the epidemiology of non-Hodgkin’s lymphoma. Clin. Lymphoma . 4 , 161–168 (2003). Choeyprasert, W. et al. Pediatric non-Hodgkin lymphoma: Characteristics, stratification, and treatment at a single institute in Thailand. Pediatr. Int. 61 , 49–57 (2019). Lymphoma Research Foundation. | Finding Cures Starts Here | LRF. https://lymphoma.org/ Faizan, M. et al. Comparison of Presentation and Outcome in 100 Pediatric Hodgkin Lymphoma Patients Treated at Children Hospital, Lahore, Pakistan and Royal Marsden Hospital, UK. J. Coll. Physicians Surg. Pak . 26 , 904–907 (2016). Mansoor, R. & Malnutrition Sepsis and Tumor Lysis Syndrome are Associated with Increased Rate of Acute Mortality in Mature B Cell Non-Hodgkin Lymphoma in Pediatric Population- Study from Tertiary Care Hospital in Pakistan. Mediterr. J. Hematol. Infect. Dis. 11 , 02019043 (2019). Kavan, P. et al. Treatment of Pediatric B-Cell Non-Hodgkin’s Lymphomas at the Motol Hospital in Prague, Czech Republic: Results Based on the NHL BFM 90 Protocols. Pediatr. Hematol. Oncol. 16 , 201–212 (1999). Smith, M. A., Altekruse, S. F., Adamson, P. C., Reaman, G. H. & Seibel, N. L. Declining childhood and adolescent cancer mortality. Cancer 120 , 2497–2506 (2014). Minard-Colin, V. et al. Non-Hodgkin Lymphoma in Children and Adolescents: Progress Through Effective Collaboration, Current Knowledge, and Challenges Ahead. J. Clin. Oncol. 33 , 2963 (2015). Wang, S., Li, S., Chen, Y. & Zhang, Y. Establishment of Risk Prediction Model and Nomogram for Lymph Node Metastasis of Cervical Cancer: Based on SEER Database. Yangtze Med. 07 , 105–115 (2023). National Childhood Cancer Registry Explorer (NCCR*Explorer. ). https://nccrexplorer.ccdi.cancer.gov/ Nahar, K. et al. Incidence and treatment outcome of childhood lymphomas in a tertiary care hospital of a developed country: a study in Combined Military Hospital Bangladesh. 10.15406/htij.2022.10.00283 Ketchen, D. Epidemiology and Treatment Outcome of Lymphomas in Children: A Study From a Developing Area in Cameroon. https : (2018). //doi.org/10.1200/jgo.18.20400 4, 12s–12s. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5539431","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":439961068,"identity":"f1086794-53e4-4b6d-9e12-a34fec37d113","order_by":0,"name":"Dania Abuhalima","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYDCCAzwMzAwMFjwMDMwHgFwJGWK1SAC1sCUwQBhEagGyeAxAfMJa+I6fPSZdUCMho9t+5vOrGzVAF7IfProBnxbJM3lp0jOOSfCYncndZp0DZDDwpKXdwKfF4ECOmTQPG1DLgdxtxjlABtA7Zvi1nH8D1PIPqOz8m2fGOf+I0XIDaAtvG0hZDvPj3DYitEjeeJdszdsHUvbMjDkXyGAj5Be+87kHb/N8s7E3O5/8+HPOtzo5fvbDx/BqQQZsEmCSWOUgwPyBFNWjYBSMglEwcgAA5Q1EBcAdY34AAAAASUVORK5CYII=","orcid":"","institution":"An-Najah National University","correspondingAuthor":true,"prefix":"","firstName":"Dania","middleName":"","lastName":"Abuhalima","suffix":""},{"id":439961069,"identity":"6aa47406-bfd8-420c-86b7-b4c80d0429fc","order_by":1,"name":"Dima Malhis","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Dima","middleName":"","lastName":"Malhis","suffix":""},{"id":439961071,"identity":"78ca979c-fc75-46fc-a705-83ea5dbd73f0","order_by":2,"name":"Zeina Qadi","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Zeina","middleName":"","lastName":"Qadi","suffix":""},{"id":439961072,"identity":"c4780e7a-208b-4370-8a50-22dad7aa7303","order_by":3,"name":"Adham Abu Taha","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Adham","middleName":"Abu","lastName":"Taha","suffix":""},{"id":439961073,"identity":"74273c23-a5b3-4854-98fb-87844a981db1","order_by":4,"name":"Sultan Mosleh","email":"","orcid":"","institution":"An-Najah National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sultan","middleName":"","lastName":"Mosleh","suffix":""},{"id":439961074,"identity":"1a5931ea-e9cc-4094-a56c-8be47480c539","order_by":5,"name":"Saed H. Zyoud","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Saed","middleName":"H.","lastName":"Zyoud","suffix":""}],"badges":[],"createdAt":"2024-11-28 05:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5539431/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5539431/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-11278-2","type":"published","date":"2025-09-26T15:57:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80276850,"identity":"0be97129-7132-453a-9c58-2e78f6ed3585","added_by":"auto","created_at":"2025-04-10 05:07:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":276943,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTreatment Outcomes of Pediatric Lymphoma Patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5539431/v1/1e292b9b1b24449258949687.jpeg"},{"id":80276847,"identity":"73109b09-0332-4534-bf45-54db5ed04911","added_by":"auto","created_at":"2025-04-10 05:07:36","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116046,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier curve for Event-Free Survival (EFS) in HL vs NHL patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5539431/v1/25e286db2e5a2e2499e1ddd9.jpeg"},{"id":80276851,"identity":"567965d2-7212-4ea1-acb0-afbc5513ee5b","added_by":"auto","created_at":"2025-04-10 05:07:36","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115277,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier curve for Overall Survival (OAS) in HL vs NHL patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5539431/v1/dc297b99725adbbe734e3a43.jpeg"},{"id":92430621,"identity":"903be332-ac5b-4d80-9d1c-ead0aa12ccca","added_by":"auto","created_at":"2025-09-29 16:06:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1504805,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5539431/v1/09f27cb1-83c5-48a6-a5e7-676462be1f0e.pdf"},{"id":80276842,"identity":"51931264-2591-4683-a921-841d557cfe1a","added_by":"auto","created_at":"2025-04-10 05:07:36","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":53458,"visible":true,"origin":"","legend":"","description":"","filename":"supplementarymaterialfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-5539431/v1/9424758f93f37075f4bdc27e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Characteristics and Short-Term Outcomes of Pediatric Lymphoma: A Retrospective Cohort Study from a Large Tertiary Hospital in a Low- and Middle-Income Country","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLymphoma, a malignancy affecting the lymphatic system, ranks as the third most prevalent cancer among children. Hodgkin lymphoma (HL) manifests in two primary forms: HL, which constitutes 6% of childhood malignancies, and non-Hodgkin lymphoma (NHL), which accounts for 7\u0026ndash;8% of pediatric cancers \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. HL, known for its high cure rates, presents pathologically as classical and nodular HL, with nodular sclerosis comprising the majority of childhood cases \u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. There are four main types of childhood NHL: lymphoblastic lymphoma (LL), which is mainly T-cell lymphoma and anaplastic large-cell lymphoma (ALCL); Burkitt\u0026rsquo;s lymphoma (BL), which is the most common NHL in children; and diffuse large B-cell lymphoma (DLBCL) \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHL comprises 6% of childhood cancers in wealthy countries. It occurs in children and adults, and its incidence is the highest in teenagers 15\u0026ndash;19 but three times lower in children aged 10\u0026ndash;14, 5\u0026ndash;9, and 0\u0026ndash;4 years. A significant male-to-female ratio of 3:1 is observed in children younger than 10 years \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. NHL, a type of cancer, accounts for 7% of childhood cancers and primarily occurs in the second decade of life. It is more common in whites and males and rarely affects children under three years of age \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. NHL has an age-adjusted incidence rate of 1.1 per 100,000, which is greater than the HL rate of 0.6 per 100,000 among children under the age of 15 \u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHL risk is linked to a family history of the first relative affected, Epstein\u0026ndash;Barr virus (EBV) activation, and primary immune deficiency \u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The risk of NHL increases with past cancer treatment \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. EBV infection may contribute to the development of NHL \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, and human immunodeficiency virus (HIV) is strongly associated with the development of NHL \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLymphomas have significant clinical and molecular variations, affecting treatment approaches \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Regardless of the patient\u0026rsquo;s presentation, the gold standard for diagnosis is an excisional biopsy, which is necessary for pathological classification \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. After that, further classification is performed by staging depending on the site and B symptoms \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDifferent lymphomas require different treatment strategies depending on their biological features \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Treatment outcomes have improved in well-resourced countries in recent years, with the 5-year relative survival rate of HL increasing to 99% and that of NHL increasing to 85\u0026ndash;95% \u003csup\u003e8\u003c/sup\u003e, with relapse being the principal cause of treatment failure \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. However, in regions with limited resources, such as Palestine, these outcomes may not be as favourable owing to challenges such as delayed diagnoses and limited access to advanced diagnostics and treatment.\u003c/p\u003e \u003cp\u003eAlthough regional studies on pediatric hematologic cancers exist, most focus on leukemia rather than lymphoma. For example, studies from An-Najah National University Hospital in Palestine and Gaza City have reported mainly on pediatric leukemia, with limited data on lymphoma treatment and outcomes \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn neighboring regions, studies have noted a higher incidence of Burkitt\u0026rsquo;s lymphoma in Gaza and the West Bank, but specific treatment outcomes for pediatric lymphoma are scarce \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Research from Israel on pediatric NHL has shown better survival rates due to access to advanced care, although these findings may not be fully applicable to Palestine \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aims to address this gap by focusing specifically on pediatric lymphoma in Palestine and analysing the clinical features and short-term outcomes of pediatric lymphoma patients treated at NNUH during our follow-up period. By providing much-needed data, this study contributes to the understanding and treatment of pediatric lymphoma in resource-limited settings.\u003c/p\u003e \u003cp\u003eOur objectives were to study the clinical profile of pediatric lymphoma patients from 2013\u0026ndash;2023 in terms of demographic data; describe the clinical history of patients at presentation and admission; and review labs for initial admission, including complete blood count; lactate dehydrogenase (LDH); bone marrow (BM) biopsy; immunohistochemistry; and whole-body computed tomography (CT) and positron emission tomography (PET) scans.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eA single-center, retrospective cohort study was conducted in 2023 at NNUH, a leading referral cancer center in the West Bank and Gaza, Palestine, to study the clinical profile and treatment outcomes of pediatric lymphoma patients treated from 1st Jan 2013 to 31st December 2022.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population and Sampling\u003c/h3\u003e\n\u003cp\u003eAmong the 96 identified patients, 75 pediatric patients (\u0026le;\u0026thinsp;18 years) with diagnosed HL or NHL treated at NNUH met the inclusion criteria. Patients were excluded if they were diagnosed at NNUH but chose to start treatment at another institution (n\u0026thinsp;=\u0026thinsp;9), had relapsed disease at initial presentation (n\u0026thinsp;=\u0026thinsp;5), or had incomplete medical records (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe collected data included demographic factors (age, sex, residence), clinical presentation (e.g., neck mass, B symptoms), lymphoma type and subtype (HL or NHL), tumor site (e.g., head/neck, mediastinal), staging (Ann Arbor for HL, St. Jude for NHL)\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, B symptoms, LDH levels (\u0026lt;\u0026thinsp;320 or \u0026ge;\u0026thinsp;320 U/L)\u003csup\u003e24\u003c/sup\u003e, and CNS and BM involvement. The outcome measures included death, relapse, remission, overall survival (OAS), and event-free survival (EFS) rates. \u003cem\u003eRelapse\u003c/em\u003e was defined as the recurrence of lymphoma after remission, which was identified by positron emission tomography (PET) or other diagnostic imaging, such as computed tomography (CT), magnetic resonance imaging (MRI), or chest X-ray. \u003cem\u003eRemission\u003c/em\u003e was defined as the absence of detectable disease activity on diagnostic imaging following treatment at the last recorded follow-up. Cures that require sustained remission over a prolonged period, typically five years or more, as suggested by the National Cancer Institute, or up to 10 years, as suggested by Cancer Research UK \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, could not be evaluated because of the study\u0026rsquo;s limited follow-up duration (mean 26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18 months). Given this timeframe, remission and EFS were used as primary outcomes, as they better reflect the short- to medium-term prognosis in pediatric lymphoma patients. Each patient's OAS status was determined on the basis of their survival at the last hospital follow-up. EFS and OAS were estimated via Kaplan‒Meier survival analysis. EFS was defined as the time from diagnosis to the first documented relapse or death from any cause, with patients who had not experienced an event at their last follow-up being censored. OAS was defined as the time from diagnosis to death from any cause, with patients who were alive at their last follow-up being censored. Survival probabilities were calculated at 2 years (24 months) on the basis of Kaplan‒Meier estimates rather than direct event counts. Patients who were transferred to another institution were censored at their last known follow-up to ensure accurate survival estimates without overestimation of mortality.\u003c/p\u003e\n\u003ch3\u003eStatistical methods\u003c/h3\u003e\n\u003cp\u003eThe data were analysed via IBM SPSS v.29.0. Continuous variables are presented as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs) or medians with interquartile ranges, whereas categorical variables are reported as frequencies and percentages. The chi-square test or Fisher\u0026rsquo;s exact test was used to analyse categorical variables. Descriptive and inferential analyses were conducted, with statistical significance set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Patients who were transferred to another hospital after completing their full treatment at our center were included in the analysis, as they met the inclusion criteria and were followed until transfer. Since their outcomes were known up to their last follow-up, they were handled as follows: In the EFS analysis, these patients were recorded as events if they experienced relapse before transfer. In the OS analysis, these patients were censored at the time of transfer in the Kaplan‒Meier survival analysis, as they were still alive at the last follow-up, but their posttransfer survival was unknown. This approach ensures that survival time \u003cb\u003eis\u003c/b\u003e accounted for without overestimating mortality.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e The study protocol was approved by the Institutional Review Board (IRB) at An-Najah National University and the clinical research center at NNUH. This approval granted access to patient clinical data, which were used exclusively for the purpose of this research. All the data were kept confidential and were not used for any other purpose. All methods were performed in accordance with the relevant guidelines and regulations, including those outlined by the Declaration of Helsinki and the journal's ethical policies for research involving human participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDemographic data\u003c/h2\u003e \u003cp\u003eAfter applying the exclusion and inclusion criteria, a collective of 75 pediatric lymphoma patients (56% from the West Bank \u0026amp; 44% from Gaza) were identified from the medical records of the pediatric oncology department of NNUH between 2013 and 2023 for enrollment in the study.\u003c/p\u003e \u003cp\u003ePatients were classified into HL (34 patients) and NHL (41 patients) groups, each analysed separately, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A male predominance was evident in both subtypes. The mean age at diagnosis was 9 years for NHL patients and 10 years for HL patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of pediatric Lymphoma patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric lymphoma(n\u0026thinsp;=\u0026thinsp;75) Frequency (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNHL(n\u0026thinsp;=\u0026thinsp;41) Frequency (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHL(n\u0026thinsp;=\u0026thinsp;34) Frequency (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at diagnosis\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (18.7)\u003c/p\u003e \u003cp\u003e22 (29.3)\u003c/p\u003e \u003cp\u003e39 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (22)\u003c/p\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003cp\u003e20 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003cp\u003e10 (29.4)\u003c/p\u003e \u003cp\u003e19 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.704*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale: Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (61.3)\u003c/p\u003e \u003cp\u003e29 (38.3)\u003c/p\u003e \u003cp\u003e1.6:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (65.9)\u003c/p\u003e \u003cp\u003e14 (34.1)\u003c/p\u003e \u003cp\u003e1.9:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (55.9)\u003c/p\u003e \u003cp\u003e15 (44.1)\u003c/p\u003e \u003cp\u003e1.3:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.476*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003cp\u003eWest Bank\u003c/p\u003e \u003cp\u003eGaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (56)\u003c/p\u003e \u003cp\u003e33 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (51.2)\u003c/p\u003e \u003cp\u003e20 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (61.8)\u003c/p\u003e \u003cp\u003e13 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.484*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003e* Fisher\u0026rsquo;s exact test\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical data\u003c/h3\u003e\n\u003cp\u003eThe process of diagnosing lymphoma involves a thorough approach with imaging techniques such as whole-body CT scans, chest X-rays, and abdominal ultrasounds, when necessary, along with bone marrow and CSF aspirations (the latter only for NHL patients). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, most NHL patients (31.7%) first presented with gastrointestinal (GI) symptoms, such as abdominal pain, masses, or signs of obstruction, whereas a majority of HL patients (70.6%) presented with neck masses. This difference in initial symptoms was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). Other symptoms observed included respiratory issues such as chronic cough and rarer signs such as facial swelling or jaw pain. At the time of diagnosis, NHL was mostly found at stage III (41.5%), whereas HL was more often diagnosed at stage II (41.2%), with fewer cases presenting at stage IV, where the disease had spread to bones, the CNS, or other organs. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, subtype analysis revealed that BL (56.1%) was the most common subtype of NHL, whereas classical nodular sclerosing Hodgkin lymphoma (73.5%) was the most common subtype of HL, with these differences being statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Immunohistochemistry was used to confirm specific markers for each subtype, ensuring accurate classification.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Characteristics of Pediatric lymphoma patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNHL n (%) (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHL n (%)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePresentation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeck mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGI symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026nbsp;(4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eB symptoms\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.109**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSite\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.018**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead/neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emediastinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabdomen/pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBM involvement\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.369*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (90.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (97.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStage\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.999*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStage early/advanced\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.819*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly\u0026thinsp;\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLDH\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.154**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (61.8))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot done\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003e*Fisher exact test **Pearson chi square test\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHistopathological findings of pediatric lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNHL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;41) (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;34) (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClassical Nodular Sclerosing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (73.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDLBCL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClassical lymphocyte rich\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClassical mixed cellularity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALCL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNLPHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003e*Pearson chi square test\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eLL, lymphoblastic lymphoma; DLBCL, diffuse large B-cell lymphoma; BL, Burkitt's lymphoma; ALCL, anaplastic large-cell lymphoma; NLPHL, nodular lymphocyte predominant HL\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOutcome\u003c/h2\u003e \u003cp\u003e Our study followed 75 pediatric lymphoma patients from diagnosis and during the completion of the treatment protocol to the last follow-up, with a mean value of 26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18 months.\u003c/p\u003e \u003cp\u003eDuring the follow-up of each patient, regular PET scans or follow-up imaging, such as CT/MRI, were employed to identify relapse and remission. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, most patients (65, 86.7%), including 29 HL (85.3%) patients and 36 NHL (87.8%) patients, experienced no events during follow-up. patients. Relapse occurred in 10 patients (13.3%), including 5 with HL and 5 with NHL. The time to relapse ranged from 1 to 54 months, with a median of 8 months and a mean of 13 months. Among the patients who relapsed, 4 patients with HL achieved remission after retreatment, whereas none of the NHL patients achieved remission. Five patients (6.7%) remained in relapse after retreatment and were transferred for further care (1 HL, 4 NHL). Since these patients experienced relapse before transfer, they were recorded as events in the EFS analysis. However, because they were still alive at their last follow-up, they were censored at the time of transfer in the OAS analysis via Kaplan‒Meier survival curves. This ensures that their survival time contributed to the analysis without overestimating mortality.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDeaths occurred in 3 patients (4.0%), all from the NHL group, including 2 patients who died without preceding relapse and 1 patient who died after relapse; thus, 96% of all patients survived. Overall, 67 patients (89.3%), including 33 HL patients and 34 NHL patients, achieved remission. Total events (relapse or death) were slightly more common in NHL patients (7 patients) than in HL patients (5 patients), and in total, 12 events (relapse or death) were recorded. During the follow-up period (mean 26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18 months), 84% of the patients experienced events (a total of 12 events, including relapse or death), with 86.7% of patients remaining event free. The 2-year event-free survival (EFS) rate was 85.1%, and the 2-year overall survival (OAS) rate was 96.6%, as estimated via Kaplan‒Meier survival analysis, as shown in supplementary Figs.\u0026nbsp;1 and 2. The chi-square test was used to examine associations between patient characteristics and treatment outcomes, and no significant correlations were found between demographic and clinical characteristics and survival or event rates, as shown in Supplementary Tables\u0026nbsp;1 and 2.\u003c/p\u003e \u003cp\u003eAdditionally, Kaplan‒Meier survival analysis was performed to compare EFS and OAS between HL patients and NHL patients. The log-rank test revealed nonsignificant differences between the groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.964 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.208), as shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Censoring is indicated in the Kaplan‒Meier curves, including for the five transferred patients in the OAS analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur research on pediatric lymphoma in Palestine represents a pioneering effort, as no such study has been conducted before. Our primary objective was to investigate the clinical characteristics of HL and NHL patients and analyse their outcomes, emphasizing distinctions between the two. Among both HL and NHL patients, males presented a greater prevalence, which aligns with findings from global research studies conducted in Egypt, Korea, the United States, East Asia, Saudi Arabia, and Turkey \u003csup\u003e\u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Notably, the male-to-female ratio in our study was approximately 2:1 for both HL and NHL, whereas in the aforementioned studies, it was commonly reported as 2.5:1, 3:1, or 4.5:1.\u003c/p\u003e \u003cp\u003eIn our study, individuals aged\u0026thinsp;\u0026gt;\u0026thinsp;10 years emerged as the predominant age group affected by pediatric lymphoma, a trend consistent with findings from research conducted in Korea and the USA \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. In contrast, studies in Turkey and India reported a higher prevalence among those aged\u0026thinsp;\u0026lt;\u0026thinsp;5 years, whereas in Egypt, the (5\u0026ndash;10 years) age category stood out \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNotably, countries exhibiting a predominance of younger age groups are often associated with a higher prevalence of EBV, which is thought to be linked to a younger age of presentation. These regional variations underscore the complex interplay between age demographics and potential viral factors influencing the incidence of pediatric lymphoma \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBL has consistently emerged as the most common pathological subtype of NHL, which aligns with other global investigations \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Conversely, HL exhibited variability in the most frequent pathological subtype across studies. Our research and studies in Egypt and the USA consistently identified classical nodular sclerosing as predominant \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Conversely, studies conducted in the UK and India reported that the mixed cellularity type was the most dominant \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of initial presentation, abdominal manifestations such as abdominal masses or abdominal signs/symptoms such as intestinal obstruction predominated in NHL patients, which is consistent with studies in other countries \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. HL patients predominantly present with neck masses or masses.\u003c/p\u003e \u003cp\u003eThe tumor\u0026rsquo;s primary site, which is the primary region of disease concentration or origin, was identified with equal frequency as the most predominant site in three regions\u0026mdash;the head and neck, abdomen and pelvis\u0026mdash;and generalized in NHL. In a study conducted in Thailand, it was in the head and neck region, and in Korea, the Prague Czech Republic and Turkey, it was mainly in the abdomen \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, the majority of patients diagnosed with NHL presented with an advanced stage (\u0026ge;\u0026thinsp;stage 3) at the time of diagnosis (53.7%). Conversely, in the HL group, there was an equal distribution, with 50% of patients diagnosed with early-stage disease (\u0026lt;\u0026thinsp;stage 3) and the remaining 50% with advanced-stage disease (\u0026ge;\u0026thinsp;stage 3). Interestingly, the literature commonly reports diagnoses of both HL and NHL at advanced stages \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eB symptoms were more common in HL patients (55.9%) than in NHL patients (36.6%). This finding was consistent with the literature in the case of NHL, whereas some studies on HL reported that the majority of patients had B symptoms, and others reported that the majority had no B symptoms \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe survival of children and adolescents with cancer has significantly increased over time \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. For children under 15 years of age, the OAS rate increased to 90% for NHL \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,42\u003c/sup\u003e and 98% for HL \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. According to American Cancer Society estimates, the OAS for HL and NHL were 99% and 91%, respectively, for children younger than 14 years. Compared with 98% and 89%, respectively, for children between 15 and 19 years of age \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, the survival rate for pediatric lymphoma patients was 96% on the basis of the survival outcome of the last hospital follow-up; 100% of HL patients and 92.7% of NHL patients survived. Similar to a study performed in Bangladesh, a total of 76.5% of patients survived; 100% of HL patients and 60% of NHL patients survived \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, relapses were observed in 9 patients, accounting for 12% of all lymphoma patients; 5 (14.7% of those with HL) and 4 (9.8% of those with NHL) of the 5 patients with HL. The EFS rate for paediatric lymphoma patients was 85.1%. Studies performed in Thailand, Korea, and East Asia among NHL pediatric patients reported similar results (71.5% \u0026plusmn; 4.3%, 67.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0%, and 84%, respectively, for 5-year EFS \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, we found no significant associations between OAS or EFS and disease stage (p\u0026thinsp;=\u0026thinsp;0.35 and p\u0026thinsp;=\u0026thinsp;0.34, respectively). These findings diverge from those of prior studies, which often reported significant associations \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e, which might be due to the small sample size of our study or the early transfer of advanced stages, which were excluded from the study.\u003c/p\u003e \u003cp\u003eTwo studies performed in East Asia and Spain reported that initial LDH levels were significantly associated with OAS and EFS and that higher LDH values were associated with poorer outcomes \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Our study, however, had no significant \u003cem\u003ep\u003c/em\u003e value for that association (0.999).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThe study's limitations include the small sample size of 75 pediatric lymphoma patients, which may limit the ability to identify significant treatment changes or generalize findings. The study was conducted at An-Najah National University Hospital, a referral center for pediatric lymphoma patients in the West Bank and Gaza. However, the hospital may not cover all cases from Gaza or the southern West Bank. The inclusion of data from pediatric cancer treatment hospitals in the West Bank was hindered by missing or incomplete medical records.\u003c/p\u003e \u003cp\u003eAdditionally, the retrospective design of this study, encompassing data collected from 2013\u0026ndash;2023, introduces inherent constraints, including potential inconsistencies in data recording and variations in follow-up durations. Patient inclusion and follow-up periods varied due to factors such as treatment completion without subsequent follow-up or transfer to specialized facilities. Notably, some patients completed their prescribed treatment regimens but did not return for scheduled follow-up assessments, limiting the ability to monitor long-term outcomes and assess sustained remission or potential late relapses. Additionally, five patients transferred to other centers were alive at their last follow-up; however, their posttransfer outcomes remain unknown, limiting the comprehensiveness of our survival analysis. Moreover, logistical and geographic challenges, particularly for patients from the Gaza Strip, limit our ability to conduct the longer-term follow-up necessary to assess cure rates. The mean follow-up duration of 26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18 months was insufficient to evaluate long-term outcomes definitively. Determining 'cure' in pediatric lymphoma patients typically requires a follow-up period of five years or more to monitor for late relapse and sustained remission. The relatively short follow-up in this study precludes the assessment of cure rates and may lead to the underestimation of late-occurring events.\u003c/p\u003e \u003cp\u003eTo mitigate these limitations, future research should consider prospective study designs with standardized data collection methods and extended follow-up periods. Such approaches would enable a more accurate assessment of long-term outcomes, including cure rates, and provide a clearer understanding of the factors influencing survival and remission in paediatric lymphoma patients.\u003c/p\u003e \u003cp\u003e Our 10-year study of pediatric lymphoma patients at NNUH provided valuable insights into their demographics and clinical characteristics, highlighting the success of their treatment protocols. However, it also highlights the need for improved cancer registries and a nationwide association for patients to improve communication and care quality.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study provides insights into the clinical characteristics and short-term outcomes of pediatric lymphoma patients in Palestine. Pediatric lymphoma is more common in males and primarily affects children over 10 years of age. HL is less prevalent, has a higher survival rate, and most commonly presents with a neck mass. In contrast, NHL is more common, is associated with higher relapse and mortality rates, and often presents with gastrointestinal symptoms. Burkitt\u0026rsquo;s lymphoma (BL) is the most common NHL subtype and is not strongly associated with B symptoms. These findings emphasize the importance of early diagnosis and continuous follow-up in optimizing treatment outcomes. However, owing to the small sample size and limited follow-up duration, long-term conclusions cannot be drawn. Further studies with larger cohorts and extended follow-up are needed to validate these findings and assess long-term survival and cure rates.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; ALCL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Anaplastic large-cell lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Burkitt\u0026rsquo;s lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Bone marrow\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Central nervous system\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CSF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Cerebrospinal fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DLBCL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; diffuse large B-cell lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; EBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Epstein\u0026ndash;Barr virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; EFS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Event-free survival\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; GI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Gastrointestinal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; HIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; human immunodeficiency virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; HL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Hodgkin lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; LDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Lactate Dehydrogenase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; LL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Lymphoblastic lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; MRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Magnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NHL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Non-Hodgkin lymphoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NNUH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; An-Najah National University Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; OAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Overall survival\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PET\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Positron emission tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: Due to the retrospective nature of this study, the need to obtain informed consent was waived by the An-Najah National University Institutional Review Board (Approval number: Med. Oct. 2023/111) and the Clinical Research Committee of An-Najah National University Hospital (Approval number: CRC_2023_0160). The study was conducted using preexisting deidentified data, and ethical approval was obtained before initiating the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analysed during the current study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eDA, DM, and ZQ collected and analysed the data and prepared the initial draft of the manuscript under the supervision of AAT, SZ and SM. AAT and SM provided critical revisions and finalized the manuscript. All authors reviewed and approved the final version of the manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: We would like to thank the An-Najah National University Hospital staff for their support during this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoard, P. P. T. E. Childhood Hodgkin Lymphoma Treatment (PDQ\u0026reg;). \u003cem\u003ePDQ Cancer Inform. Summaries\u003c/em\u003e (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandlund, J. T., Downing, J. R. \u0026amp; Crist, W. M. Non-Hodgkin\u0026rsquo;s lymphoma in childhood. \u003cem\u003eN Engl. J. Med.\u003c/em\u003e \u003cb\u003e334\u003c/b\u003e, 1238\u0026ndash;1248 (1996).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlank, O. et al. 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Epidemiology and Treatment Outcome of Lymphomas in Children: A Study From a Developing Area in Cameroon. \u003cem\u003ehttps\u003c/em\u003e: (2018). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e//doi.org/10.1200/jgo.18.20400\u003c/span\u003e\u003cspan address=\"http:////doi.org/10.1200/jgo.18.20400\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e 4, 12s\u0026ndash;12s.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lymphoma, Pediatric patients, Treatment outcome, Retrospective studies","lastPublishedDoi":"10.21203/rs.3.rs-5539431/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5539431/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe incidence of childhood cancer has increased, with lymphoma being the third most common malignancy in children and showing improved survival rates. This study aimed to analyse the demographic, clinical, and outcome data of pediatric lymphoma patients, compare the characteristics of the HL and NHL subtypes, and evaluate treatment outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA single-center retrospective cohort study was conducted at An-Najah National University Hospital (NNUH) in Palestine from 2013\u0026ndash;2023. Seventy-five pediatric patients (\u0026le;\u0026thinsp;18 years) newly diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) were included, and data from electronic medical records were used. Follow-up data were analysed via Kaplan\u0026ndash;Meier survival curves to determine event-free survival (EFS) and overall survival (OAS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis study revealed a male predominance in both NHL (1.9:1) and HL (1.3:1) patients, with a mean age of 9 years for NHL patients and 10 years for HL patients. The majority of patients were from the West Bank (56%) or Gaza (44%). NHL patients commonly presented with GI symptoms (31.7%), whereas HL patients (70.6%) presented with neck masses. B symptoms were more common in HL patients (55.9%). The tumor stage also differed, with NHL often being stage III and HL being stage II. The predominant subtypes were Burkitt\u0026rsquo;s lymphoma (BL) for NHL and classical nodular sclerosis for HL. Overall survival was 96%, with 4% mortality. During the follow-up period (mean 26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18 months), 84% of the patients had events, with 86.7% of patients remaining event-free. Relapse occurred in 13.3% of patients, predominantly in the NHL group, and the prevalence of OAS was 96%. The 2-year event-free survival (EFS) rate was 85.1%, and the 2-year overall survival (OAS) rate was 96.6%, as estimated via Kaplan‒Meier survival analysis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study provides insights into the clinical characteristics and short-term outcomes of pediatric lymphoma patients in Palestine. Pediatric lymphoma is more common in males and primarily affects children over 10 years of age. HL is less prevalent, has a higher survival rate, and most commonly presents with a neck mass. In contrast, NHL is more common, is associated with higher relapse and mortality rates, and often presents with gastrointestinal symptoms. Burkitt\u0026rsquo;s lymphoma (BL) is the most common NHL subtype and is not strongly associated with B symptoms. These findings emphasize the importance of early diagnosis and continuous follow-up in optimizing treatment outcomes. Further studies with larger cohorts and longer follow-up periods are needed to validate these findings and assess long-term survival and cure rates.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics and Short-Term Outcomes of Pediatric Lymphoma: A Retrospective Cohort Study from a Large Tertiary Hospital in a Low- and Middle-Income Country","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 05:07:31","doi":"10.21203/rs.3.rs-5539431/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-04T06:49:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-02T08:58:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166070342597011714129610624490900863429","date":"2025-04-08T08:16:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-05T03:51:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T15:25:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-24T07:19:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92e3bf81-e97e-4f31-bb54-193e43de6024","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46836190,"name":"Health sciences/Diseases/Cancer/Paediatric cancer"},{"id":46836191,"name":"Health sciences/Health care/Diagnosis/Neoplasm staging"}],"tags":[],"updatedAt":"2025-09-29T16:03:26+00:00","versionOfRecord":{"articleIdentity":"rs-5539431","link":"https://doi.org/10.1038/s41598-025-11278-2","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-09-26 15:57:45","publishedOnDateReadable":"September 26th, 2025"},"versionCreatedAt":"2025-04-10 05:07:31","video":"","vorDoi":"10.1038/s41598-025-11278-2","vorDoiUrl":"https://doi.org/10.1038/s41598-025-11278-2","workflowStages":[]},"version":"v1","identity":"rs-5539431","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5539431","identity":"rs-5539431","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}